Provider Demographics
NPI:1710975008
Name:PRESIDENTIAL MOBILITY
Entity Type:Organization
Organization Name:PRESIDENTIAL MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DME MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-330-4990
Mailing Address - Street 1:PO BOX 10665
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0046
Mailing Address - Country:US
Mailing Address - Phone:479-332-4990
Mailing Address - Fax:479-332-4290
Practice Address - Street 1:2889 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3413
Practice Address - Country:US
Practice Address - Phone:479-332-4990
Practice Address - Fax:479-332-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141768784Medicaid
AR48128OtherBLUE CROSS BLUE SHIELD
AR130311772Medicaid
AR137085716Medicaid